Visiting "La Casa del Abue"

It’s no secret that the family system in Mexico and the US are very different. Generally in the States, grandparents are not included in the immediate family, which means they don’t live with their children. Not always the case, but the truth is… nursing homes often become “home” for the elderly when they can no longer take care of themselves. In Mexico, abuelitos are highly-respected members of the nuclear family, and their health and happiness are of interest to their children. This is the primary reason behind the federal government creation of “La Casa del Abue” (LCDA) – the first of it’s kind located in Puebla, Mexico.

When I say the “federal government,” I mean the institution located within the fed gov recognized as DIF (sistema estatal para el desarrollo integral de la familia). The purpose of DIF is to promote the general health of the people, and in particular… of Mexican families. Through DIF, LCDA was created in 2006. The mission of LCDA, is to provide the elderly (over 60 years) with the tools and space to maintain a healthy, active life-style, while helping them to remain an important part of the nuclear family and community. In the US, such places are commonly called “American Legions” but only offer activities such as Bingo and board games. LCDA is a place that is both a health clinic, providing all types of medical services, as well as offering social activities – fully promoting the general well-being of the elderly (physical and mental health). It is not a place for living, like a nursing home, but a community center with medical services. 

For example, the clinical part of LCDA provides the following services: medical doctor, dentist, nutritionist, psychologist, cardiologist, optometrist, and physical therapy. However, services also include other forms of therapy including acupuncture, water-pressure therapy, heat-therapy, laser-therapy and other treatments that I am not familiar with. The activities offered are seemingly-endless. There’s aquaerobics at the pool, all types of dance classes, singing, instrumental music, board games, pilates, Taichi, yoga, zumba (VERY popular in LatinAmerica), wood-shop, baking class, cooking class reading at the library, trips to nearby locations… like I said, ENDLESS. I can’t even begin to tell you how impressed I was with everything that LCDA had to offer. The atmosphere could only be described as being fun and healthy. In the tradition of most building of Mexico, the entire activity space is open, full of natural light, and comfortable.

LCDA also has a dining hall that serves lunch everyday. The menu is created by the kitchen staff, and reviewed by the nutritionist. Karla is the only nutritionist on-staff and she also calculates the amount of calories, protein, fat, and carbohydrates for each food item. The menus are posted outside the cafeteria clearly showing the nutritional value for the day. Every meal is cooked without salt, no sugar, low in cholesterol and with very little fat. In this manner, the meals are healthy and acceptable for all people with a variety of conditions (diabetes, renal disease, heart disease, etc.) The meal for the day when I visited included: pea soup, melon water (water flavored with a bit of pureed fruit is very common in Latin America), crackers, tuna Mexicana and yogurt with granola. The meal was calculated to have 564kcals, 22.9g PROT, 13.7g Fat, 69.1g CHO.

The consideration that goes into creating this daily healthy menu is both impressive and a challenge. To create meals that limit salt, sugar, fat, etc AND taste good is no easy job. Kudos to LCDA, the kitchen staff and K. the nutritionist!

On that note, it’s important to mention how servicing the elderly population can be both demanding and challenging. In my opinion, it’s probably the most difficult population to work with for many reasons:

1. Older people have had diets and eating patters for a very long time, they are often reluctant to change what they eat or how they cook.
2. They may not be independent any longer and depend on family or other persons to cook their meals, which means we have to educate those who are making the food choices.
3. Food is a comforting part of life, deeply tied to the psyche. Asking someone who is sick, depressed, stressed or just plain exhausted with life, to change the way they eat may be asking too much. If food is one of the few things they truly enjoy, how can we justify the additional stress change may add to their life?
4. There’s the old and the very old. I can’t really imagine telling a 90 year old woman to cut-back on the cookies and cake. There’s a difference between helping someone to develop a healthier diet that will have positive effects in the future, and just being silly. She’s 90, let her eat what she wants!
5. Food safety is a HUGE concern. The elderly population is one that is immuno-compromised, which means that they can become easily sick from the bacteria in normally and not normally found in food. Not only do they become sick more easily, but it can be difficult or impossible to recover from a sickness. Without a strong ability to fight off invading bacteria, simple infections that a healthy normal adult quickly recovers from can become the kiss of death for an elderly person with a weakened immune system. For these reasons, certain foods should be avoided, everything needs to be cooked properly and measures need to be taken to prevent cross-contamination.
6. Servicing the elderly population will also mean treating patients with a large variety of conditions that affect their food intake. Renal disease, heart disease, diabetes, cancer, malnutrition, over-nutrition, diarrhea, constipation and so-forth.
7. Dental problems affect food intake. A person with dentures, few death or mouth pain may not be able to eat solid foods.
8. There’s happy old people and miserable old people. Everyone knows that sometimes a cranky old man or woman has no respect for what you tell them and no tolerance to listen to you anyways. It’s important to have a FIRM hand while being understanding.
9. Medical treatments and medications have serious side-effects that could affect food-intake. Severe diarrhea, dehydration, loss of the sense to taste or smell, nausea… may cause a person to be afraid of eating or have a loss of appetite. A low intake of food in an elderly person is common, so it’s important to relieve the underlying caused or suggest ways to make food more palatable.
10. Communication - sometimes when we get old we can't think, talk or speak so well. Somehow as nutritionists we need to communicate effectively despite any barriers. 

That’s A LOT of things to think about when you’re trying to assess the nutritional status of a client. I’m not saying it’s impossible, but it’s certainly challenging and depends on each individual patient. You need to use your best judgment in every situation and also, don’t forget to be compassionate.

For the last part of my visit to LCDA, I was able to stay in the office with K. while she had a consultation with a patient. Every patient has a file they bring with them, so the medical records and current treatments are all visible to each health professional. In this way, the patient doesn’t have to repeat all of their medical history, etc. etc. during each consult. After reviewing the records, the nutritionist measures height, weight, BMI and completes a 24-hour recall (which we know is not very accurate, but it’s the best tool we have). Based on this information, the nutritionist will make very general recommendations: try to eat more vegetables, drink low-fat milk, drink more water, and suggest supplements (vitamins, Metamucil, etc.) that will be helpful in relieving diet-related conditions and generally improve the quality of life. Also, as much as you would like to avoid this topic, it’s important to ask about bowel movements. That’s right, “how many movements?” and “what does your poop look like?” NEED to be asked. As I mentioned above, diarrhea and constipation can have severe impacts on the food-intake and comfort of a patient. Relieving these conditions are necessary but not always easy to do.

Something I did not mention already, is “how do the people who visit LCDA” afford the services? La Casa del Abue is of no charge to persons over 60 years. The X-rays, treatments, doctor consults, dentist visits are all free. Generally the activities are free as well, or they may be very very affordable. The whole point is to take-care of our elderly population, while promoting their physical and mental well-being. In Mexico, they do not forget their grandparents. They are a vital part of the family system and need to be cared for in ways other than providing financial support. I haven’t  quite figured out well LCDA is being funded completely by the government, and since it’s fairly new, I’m not sure if it will be maintained over-time. For the members of the Poblano community, I hope La Casa del Abue will continue to be an affordable resource for maintaining all aspects of health later in life – and a model for similar programs in the future.

INTERNING TIPS

1. Don’t let yourself become overwhelmed when working with a difficult patient or population. You are a professional.

2. Let’s not forget that the elderly are a VERY difficult population to service, for all the above-mentioned reasons.

3. No matter who your patient is, find the balance between having a firm approach while being compassionate.

4. Remember to ask about poop – addressing basic issues of diarrhea and constipation can seriously improve quality of life.

5. Nutrition is NOT always a science. Never forget to use some common sense and your best judgment, it will benefit both you AND your patient.

For more information check out http://www.casadelabue.gob.mx/CAPortal/ or http://www.dif.pue.gob.mx/index.php

 

Ciao!